Antimicrobial Prescription Practices in the Veterinary Clinics of Addis Ababa, Ethiopia Temesgen Kifle 1 and Getachew Tadesse 1 * 1 Department of Biomedical Sciences, College of Veterinary Medicine and Agriculture, Addis Ababa University, P.O.Box 34, Debre Zeit, Ethiopia, getadesse1@yahoo.com *Corresponding author Abstract The objectives of this study were to assess the adherence of animal health workers to rational antimicrobial prescription guidelines. Data were collected from personnel working in 25 clinics by using structured questionnaires. The data included the methods of diagnosis and drug selection, the frequently prescribed antimicrobials, methods of prescription and the availability of drug information sources. The study showed that diagnosis was established on a presumptive basis; pen-strep and oxytetracycline were the frequently prescribed drugs and verbal instruction was a common form of prescription. Adherence to the rational guidelines was substantially low and the prescription practices favor the selection of drug resistant pathogens. Educational programs are needed to ensure the perceived benefit of animals and reduce the rates of emergence of drug resistant pathogens of animal origin in Ethiopia. Keywords: Addis Ababa, Animals, Antimicrobials, Health workers, Prescriptions Introduction The irrational use of drugs is a major problem in present day clinical practices as it could result in toxicities and treatment failures in patients and in the emergence of drug resistant pathogens (Bisht et al., 2009). Whilst drug resistant bacteria were traditionally acquired in hospitals due to high antimicrobial use and disease transmission rate, community acquired drug resistant bacteria are becoming increasingly common (Nelson et al. 2009). Resistance may escalate to the point at which the efficacy of drugs will no more be predictable and infections once treatable could become untreatable (Morley et al., 2005). 65
The occurrence of drug resistant bacteria in animals and animal products (Demelash Biffa et al., 2003; Bayleyegne Molla et al., 2006; Wassie Molla et al., 2006; Endrias Zewdu and Cornelius, 2009; Behailu Bekele and Mogessie Ashenafi, 2007; Zelalem Addis et al, 2011) and humans were reported (Mulugeta Kibret and Bayeh Abera, 2010, Dagnew et al., 2013). Although the relationship between antimicrobial use and antimicrobial resistance is complex, increased levels of antimicrobial resistance is thought to be positively associated with higher levels of antimicrobial usage (Bronzwaer et al., 2002). The irrational use of antimicrobials in farm animals also fosters the emergence of antimicrobial resistant micro organisms (Aarestrup et al., 2001). Non adherences of health professionals to rational drug prescribing and dispensing guidelines were recorded (Legese Chelkeba, 2013; Abebe Zeleke et al. 2014). However, reports on the appropriateness of the prescribing and dispensing behaviors of animal health workers are limited. The objectives of this study were to assess the adherence of animal health workers to rational antimicrobial prescription guidelines. Materials and methods The study was conducted in Addis Ababa from November 2009 to April 2010. A total of 52 veterinary clinics (8 public and 44 private) that provided services to an estimated animal population of 66,766 cattle, 28,486 small ruminants, 7,774 equines, 360,684 pets and 360,777 poultry (AACUAD, 2005) were considered. Twenty five clinics (8 public and 17 private) were selected on the based on their accessibility, functional status and willingness of the personnel to participate in the study. Data on the methods of diagnosis and drug selection, the frequently prescribed drugs and prescription methods, availability of information sources and encountered treatment failures were collected by using a structured questionnaire. Descriptive statistics were used to describe the data. Results Fifteen (15/25) health personnel had a degree in Veterinary Medicine and 10 a diploma. The median duration of experience was 10 years (range = 4 to 22 years). Fifteen of the 17 private clinics were run by the owners themselves. Clinical signs, history and epidemiology were the main methods used to establish a diagnosis (25/25) and laboratory methods were reported by three re- 66
spondents. Availability was the first factor considered in drug selection (Table 1) and pen-strep was the most frequently prescribed antibacterial (Table 2). Table 1. Frequencies of respondents (n= 25) on factors considered in drug selection. Factors Frequencies of respondents 1 st rank 2 nd rank 3 rd rank Efficacy 1 16 6 Safety 0 2 8 Cost 0 6 10 Availability 24 0 1 Table 2. Frequencies of respondents (n= 25) on the availability and ranks of the frequently prescribed drugs. Antimicrobials Availability Prescription rank 1 st 2 nd 3 rd Penicillin G 22 0 0 22 Pen- strep 25 22 3 0 Aminoglycosides 5 0 0 0 Oxytetracycline 25 3 18 0 The importance of, combination therapy, use of narrow spectrum agents before broad spectrum agents, use of antibacterial agents for prophylactic purposes and use of older drugs than newer agents were considered by 0/25, 2/25, 10/25 and 12/25 of the respondents respectively. Verbal prescription was a common form of prescription (Table 3) by both diploma (7/10) and degree holders (10/15). Table 3. Frequencies of respondents (n= 25) on drug prescription methods Prescription methods Ownership Number Verbal Written Verbal/Written Private 17 12 1 4 Public 8 5 3 0 Total 25 17 4 4 Treatment failures were reported by 10 respondents. Essential drug lists and standard treatment guidelines were available in 16 and 18 of the clinics respectively. 67
Discussion The study demonstrated that most health workers did not adhere to the rational antimicrobial prescription guidelines. The diagnosis of a disease was generally presumptive; drug sensitivity tests were not carried out and the selection of drugs was primarily based on their availability rather than their efficacy. In addition, a few antimicrobials were commonly prescribed and factors that could help reduce the rates of emergence of resistant pathogens were not considered by most respondents. Moreover, verbal prescription was the major form of prescription and the prescription papers used in some clinics did not contain all the relevant information. In general the prescription practices are suggestive evidences of the reported treatments failures and potentially contribute to the occurrence of resistant pathogens. In a study on the antimicrobial resistance features of salmonella isolates of dairy cattle in Addis Ababa, almost all isolates (20/21) were multi drug resistant (Zelalem Addis, 2011). Although published studies on the drug prescription behaviors of animal health workers in Ethiopia is not available, non-adherence to rational antimicrobial prescription guidelines were recorded in several hospitals in Ethiopia (Legese Chelkeba, 2013; Abebe Zeleke et al., 2014). The penicillins were the most frequently prescribed drugs (Antenh Assefa Desalegn, 2013; Endale Getachew et al., 201). Inappropriate selection of drugs, over prescription of drugs and inappropriate treatment duration were recorded in several private and public health facilities (Bayew Tsega and Eyasu Makonnen, 2012). Essential drug lists and standard treatment guidelines were available in more than half of the clinics. However the responses of the interviewees depict that the information sources were not properly used. Guidelines could only be useful if professionals know their importance and are committed to their application. Studies elsewhere show that educational programs are more effective than guidelines alone (Laing et al., 2001) and were reported to have improved the diagnostic qualities of health workers and reduced unjustified prescriptions (Chuc et al., 2002). Cognizant of the similarities of the facilities, personnel qualifications and drug availabilities all over the country, the results could be extrapolated to other clinical settings in Ethiopia. The overall prescribing practices require attention, and animal health workers should be updated in order to ensure the perceived benefit of the animals and reduce the risk to public health. 68
References AACUAD. 2005. Updated Animal Population Census. Addis Ababa City Urban Agricultural development Bureau, Addis Ababa. Aarestrup, F. M. A. M., Seyfarth, H. D., Emborg, K., Pedersen, R. S., Hendriksen, R.S. and Bager, F., 2001. Effect of abolishment of the use of antimicrobial agents for growth promotion on occurrence of antimicrobial resistance in fecal enterococci from food animals in Denmark. Antimicrob. Agents Chemother. 45 (7), 2054-2059. Addis, Z., Kebede, N., Worku, Z., Gezahegn, H., Yirsaw, A, and Kassa, T., 2011. Prevalence and antimicrobial resistance of Salmonella isolated from lactating cows and in contact humans in dairy farms of Addis Ababa: a cross sectional study. BMC. Infect. Dis., 11, 222. doi: 10.1186/1471-2334-11-222. Bekele, B., and Ashenafi, M., 2010. Distribution of drug resistance among Enterococci and Salmonella from poultry and cattle in Ethiopia. Trop. Anim. Health. Prod., 42(5), 857-864. Biffa, D., Tareke, F., and Sahile, M., 2003. Antibiotic Sensitivity of Mastitis Causing Bacteria Isolated From Dairy Cows in Welayta Soddo, Southern Ethiopia. Eth. J. Anim. Prod., 3(1), 131-141. Bisht, R., Katiyar, A., Singh, R. and Mittal, P., 2009. Antibiotic resistance a global issue of concern. Asian J. Pharm. Clin. Res., 2 (2), 34-39. Bronzwaer, S.L., Cars, O., Buchholz, U., Molstad, S., Goettsch, W., Veldhuijzen, I.K., Kool, J.L., Sprenger, M.J. and Degener, J.E., 2002. A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg. Infect. Dis., 8, 278 282. Chuc, N. T., M., Larsson, N. T., Diwan, D, V. K., Tomson, G. B. and Falkenberg, T. 2002. Improving private pharmacy practice: a multi-intervention experiment in Hanoi, Vietnam. J. Clin. Epidemiol, 55 (11), 1148-1155. Dagnew, M., Yismaw, G., Gizachew, M., Gadisa, A., Abebe, T., Tadesse, T,, Alemu, A. and Mathewos, B., 2013. Bacterial profile and antimicrobial susceptibility pattern in septicemia suspected patients attending Gondar University Hospital, Northwest Ethiopia. BMC Res. Notes.,;6,283. doi: 10.1186/1756-0500-6-283. Desalegn, A.A., 2013. Assessment of drug use pattern using WHO prescribing indicators at Hawassa University teaching and referral hospital south Ethiopia: a crosssectional study. BMC. Health Serv. Res., 13, 170. doi: 10.1186/1472-6963-13-170. Getachew, E., Aragaw, S., Adissie, W., and Agalu, A., 2013. Antibiotic prescribing pattern in a referral hospital in Ethiopia. Afr. J. Pharm. Pharmacol., 7(38), 2657-2661. 69
Kibret, M. and Abera, B., 2010. Antimicrobial Resistance Trend of Bacteria from Clinical Isolates: An 8-Year Retrospective Study at Dessie Regional Laboratory, Northeast Ethiopia. Ethiop. Pharm. J., 28, 39-46. Laing, R., Hogerzeil, H. and Ross-Degnan, D. 2001. Ten recommendations to improve use of medicines in developing countries. Health. Policy Plan., 16 (1), 13-20. Molla, B, Berhanu, A., Muckie, A., Cole, L., Wilkie, E., Kleer, J., Hildebrandt, G., 2006. Multidrug Resistance and Distribution of Salmonella Serovars in Slaughtered Pigs. J. Vet. Med., 53 (1), 28-33. Molla, W., Molla, B., Alemayehu, D., Muckie, A., Cole, L., Wilkie, E., 2006. Occurrence and antimicrobial resistance of Salmonella serovars in apparently healthy slaughtered sheep and goats of central Ethiopia. Trop. Anim. Hlth. Prod., 38(6), 455-462. Morley, P.S., Apley, M.D., Besser, T.E., Burney, D.P., Fedorka-Cray, P.J., Papich, M.G., Traub-Dargatz, J.L., and Weese, J.S., 2005. Antimicrobial drug use in veterinary medicine. J.vet. Intern. Med., 19(2), 617-629. Nelson, N., Joshi M., and Kirika, R., 2009. Antimicrobial Resistance: The Need for Action in the East, Central and Southern Africa Region. Submitted to the U.S. Agency for International Development by the Strengthening Pharmaceutical Systems (SPS) Program. Arlington, VA: Management Sciences for Health. Tsega, B., and Makonnen, E., 2012. Comparative evaluation of drug prescription appropriateness in public and private health institutions of South West Ethiopia: the case of Wolkite town. IJPSR., 3, 4922-4928. Zeleke, A., Chanie, T. and Woldie, M., 2014. Medication prescribing errors and associated factors at the pediatric wards of Dessie Referral Hospital, Northeast Ethiopia. International Archives of Medicine, 7, 18, http://www.intarchmed.com/content/7/1/18. Zewdu, E. and Cornelius, P., 2009. Antimicrobial resistance pattern of Salmonella serotypes isolated from food items and personnel in Addis Ababa, Ethiopia. Trop. Anim. Health. Prod., 41(20), 241-249. 70